can surgery improve neurological function in penetrating ... · spinal cord injury from spinal gsws...

Neurosurg Focus / Volume 28 / May 2010

Neurosurg Focus 28 (5):E4, 2010

1

Patients with PSIs present very complex, multi-disciplinary management challenges for military surgeons. Not only can the patient have immedi-

ate and delayed life-threatening damage to organs along the path of the projectile, the spinal column and possibly the neurological structures contained within can also, by definition, suffer injury, the severity of which depends on multiple factors. Spinal cord injury from spinal GSWs is more often a complete lesion with a decreased poten-

tial for neurological recovery than with closed trauma.43 There are a number of potential surgical indications, the most controversial of which is whether decompressive laminectomy has any effect on neurological recovery. Medical civilian and military literature is replete with opinions for and against the use of surgery.

Although missile characteristics such as size, compo-sition and design are important, the major determinant of the destructive ability of a projectile is velocity at impact and thus the kinetic energy imparted to the surrounding tissue.10 Energy is calculated based on mass and velocity as follows: energy = 1/2mv2. Therefore, velocity has a sig-nificantly greater effect on energy than projectile mass.

Can surgery improve neurological function in penetrating spinal injury? A review of the military and civilian literature and treatment recommendations for military neurosurgeons

Paul Klimo Jr., m.D., m.P.H.,1 Brian T. ragel, m.D.,2 micHael rosner, m.D.,3 Wayne gluf, m.D.,4 anD ranDall mccafferTy, m.D.5

188th Medical Group, Wright-Patterson Air Force Base, Ohio; 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon; 3Division of Neurosurgery, Walter Reed Medical Center, Washington, DC; 4Naval Medical Center, San Diego, California; and 5Wilford Hall Medical Center, Lackland Air Force Base, Texas

Object. Penetrating spinal injury (PSI), although an infrequent injury in the civilian population, is not an infre-quent injury in military conflicts. Throughout military history, the role of surgery in the treatment of PSI has been controversial. The US is currently involved in 2 military campaigns, the hallmark of both being the widespread use of various explosive devices. The authors reviewed the evidence for or against the use of decompressive laminectomy to treat PSI to provide a triservice (US Army, Navy, and Air Force) consensus and treatment recommendations for military neurosurgeons and spine surgeons.

Methods. A US National Library of Medicine PubMed database search that identified all literature dealing with acute management of PSI from military conflicts and civilian urban trauma centers in the post–Vietnam War period was undertaken.

Results. Nineteen retrospective case series (11 military and 8 civilian) met the study criteria. Eleven military articles covered a 20-year time span that included 782 patients who suffered either gunshot or blast-related projectile wounds. Four papers included sufficient data that analyzed the effectiveness of surgery compared with nonoperative management, 6 papers concluded that surgery was of no benefit, 2 papers indicated that surgery did have a role, and 3 papers made no comment. Eight civilian articles covered a 9-year time span that included 653 patients with spinal gunshot wounds. Two articles lacked any comparative data because of treatment bias. Two papers concluded that decompressive laminectomy had a beneficial role, 1 paper favored the removal of intracanal bullets between T-12 and L-4, and 5 papers indicated that surgery was of no benefit.

Conclusions. Based on the authors’ military and civilian PubMed literature search, most of the evidence suggests that decompressive laminectomy does not improve neurological function in patients with PSI. However, there are serious methodological shortcomings in both literature groups. For this and other reasons, neurosurgeons from the US Air Force, Army, and Navy collectively believe that decompression should still be considered for any patient with an incomplete neurological injury and continued spinal canal compromise, ideally within 24–48 hours of injury; the patient should be stabilized concurrently if it is believed that the spinal injury is unstable. The authors recognize the highly controversial nature of this topic and hope that this literature review and the proposed treatment recommenda-tions will be a valuable resource for deployed neurosurgeons. Ultimately, the deployed neurosurgeon must make the final treatment decision based on his or her opinion of the literature, individual abilities, and facility resources avail-able. (DOI: 10.3171/2010.2.FOCUS1036)

Key WorDs • penetrating spinal injury • spinal gunshot wound • blast injury • military • decompression • laminectomy • outcome

1

Abbreviations used in this paper: GSW = gunshot wound; IED = improvised explosive device; PSI = penetrating spinal injury; SCI = spinal cord injury; VB = vertebral body.

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P. Klimo et al.

2 Neurosurg Focus / Volume 28 / May 2010

Civilian spinal GSWs are generally caused by low muzzle velocity (< 1000 ft/second) handguns, whereas military injuries may be due to high-velocity assault weapons or fragments from IEDs. For example, the muzzle velocities of the M-16 and AK-47 are approximately 3300 and 2810 ft/second, respectively.11 A bullet damages tissues and structures by the following 3 known mechanisms: 1) di-rect impact injury of the bullet along its path; 2) pressure or shock waves created by the bullet impacting on tissue; and 3) temporary cavitation. Spinal cord injury may there-fore occur even without any obvious injury to the spinal canal, termed spinal cord concussion (Fig. 1). Given the differences in ballistics and other factors discussed below, one may reasonably infer that penetrating injuries received on the battlefield are more destructive and therefore carry a worse prognosis than their civilian counterparts.

The US is currently engaged in 2 major military con-flicts, Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom. These conflicts have seen the use of explosive weapons, most notably the IED as the weapon of choice that is used by adversaries.34 Conven-

tional assault weapons, however, are still used. The stimu-lus for this paper was the frequent admission of patients with PSIs seen by the primary author during his recent deployment to Afghanistan and the challenge posed in determining the optimal treatment. Current neurosurgery clinical practice guidelines available to neurosurgeons in deployed locations do not address the management of PSIs. The most important question that the neurosurgeon faces is whether a decompressive laminectomy can im-prove the chance of regaining lost neurological function. The goal of this paper is to review in detail the civilian and the military medical literature over the last 30 years to develop an evidence-based answer to this age-old question and to put forth succinct treatment recommendations for the management of war-related PSIs. This triservice (US Air Force, Army, and Navy) effort will hopefully enable the deployed military neurosurgeon to make the most in-formed decision in a timely fashion and ultimately provide the best care for troops.

MethodsApplying specific search terms, we used the US Na-

tional Library of Medicine PubMed database to identify all articles dealing with PSIs in military conflicts, partic-ularly in the post–Vietnam War period. To identify addi-tional articles not identified by PubMed, the reference lists of appropriate articles were hand searched. We selected the post–Vietnam War period to capture management of spinal injuries in a relatively modern era of military med-icine that reflected state-of-the-art battlefield evacuation and stabilization, and resuscitative, surgical, and postop-erative care. This was done to achieve a balance between minimizing the chance that potentially antiquated medi-cal care (> 25–30 years) would confound the results of surgical intervention, and collecting an adequate amount of medical literature on an infrequently published topic. Information identified in each article, when available, in-cluded the number of patients, average age, sex, military conflict, mechanism of injury, level of spinal involvement (cervical, thoracic, or lumbosacral), incomplete versus complete neurological injury, number of patients who un-derwent decompressive laminectomy, surgical outcomes, and incidence of injury to other organs or organ systems.

Since there were relatively few military articles iden-tified during the post–Vietnam War period, a similar search was conducted to identify all papers dealing with civilian PSIs during a similar time span. The same infor-mation from each article was recorded.

ResultsMilitary Literature

Eleven retrospective case series were identified in the 20 years that spanned 1984–2004 (Tables 1 and 2). Coun-tries where the conflicts took place included Croatia (3 re-ports21,36,40), Turkey (3 reports2,12,22), Iran-Iraq (1 report1), Lebanon (2 reports13,30), India (1 report6), and Panama (1 report31). There were 782 patients collectively, the major-ity being male and soldiers, although some papers also identified civilians as part of their patient population. The

Fig. 1. Example of a spinal cord concussion with incomplete neu-rological injury. This 13-year-old male was tending his flock of camels when he was struck at the base of the neck just above the left clavicle (A, arrow) with an exit wound on the right medial aspect of the scapula (B). The weapon was thought to be an AK-47. The bullet traversed the T-3 and T-4 (C) VBs, but there was no canal compromise. The patient had no motor or sensory function in his legs but evidence of sacral spar-ing. The patient was treated nonoperatively; the spine was not believed to be unstable.


Can surgery improve neurological function in PSIs?

3

mean age ranged from 20 to 39 years, the latter being the average from a group of injured citizens included in one report.21 Gunshot wounds were clearly identified as the mechanism in 333 patients and fragmentation from an explosive device in 378. One paper did not make the distinction between the two mechanisms.13 Two papers specified the kinetics of the weapon used (low velocity vs high velocity).6,12 The thoracic spine was most com-monly involved (317 [41%] of 782 patients), followed by lumbosacral (285 [36%] of 782 patients) and cervical (180 [23%] 782 patients). Of the 606 patients in whom their admission neurological function was known, 306 (50%) had a complete SCI. Decompressive laminectomy was performed in 382 patients, 31 of whom underwent stabili-zation as well. Associated organ injuries occurred in 45% of patients (350 of 775).

Only 4 papers had sufficient data to allow any conclu-sion to be drawn regarding the efficacy of decompressive surgery compared with conservative management (Table 2). The other papers either did not present adequate pre- and postoperative neurological data or were biased in their treatment (that is, they treated all patients either surgically or nonoperatively), thus rendering any comparison impos-sible. Despite presenting inadequate supportive data, the authors of 4 other papers rendered a position statement on the role of surgery. Overall, 6 papers concluded that decom-pressive surgery was of no benefit, 2 indicated that surgery was a benefit in all patients with a neurological deficit (1 report) or only in those with an incomplete or cauda equina injury (1 report), and 3 papers made no comment.

Civilian LiteratureEight retrospective case series met our search crite-

ria in the 9 years that spanned 1987–1996 (Tables 3 and 4). Although 2 papers were published in the post–Viet-nam War era, their data collection occurred during the Vietnam War era and thus were excluded.17,41 Metropoli-tan trauma centers included Philadelphia (2 reports16,25),

Houston (2 reports35,38), Los Angeles (1 report45), Shreve-port (1 report5), Chicago (1 report9), and The Bronx (1 report23). There were 694 patients collectively, the vast majority being male (639 patients). The mean age ranged from 24.7 to 32 years. Gunshot wounds from low-velocity handguns were the most common mechanism. Although some series also included patients with stab wounds, the neurological data in Table 4 reflect only those patients with GSWs, but some of the demographic data in Table 3 includes the stab wound victims. The thoracic spine was again the most commonly involved region (360 [52%] of 694), followed by lumbosacral (236 [34%] of 694), and cervical (98 [14%] of 694). Of the 633 patients in whom the admission neurological function was known, 377 (60%) had a complete SCI. Decompressive laminectomy was performed in 231 patients, and only 9 underwent con-current stabilization. Associated organ injuries occurred in a high percentage of patients (356 [77%] of 461).

Only 2 papers had sufficient data to draw any conclu-sion on the efficacy of decompressive surgery compared with conservative management (Table 4). This was due to treatment bias. Cybulski et al.9 operated on all patients; Kihtir et al.23 did not operate on any patient. Despite lack of comparative data in these 2 papers, the authors of all papers rendered an opinion on the role of surgery based on their experience. Overall, 2 papers concluded that de-compressive surgery had a beneficial role (in cauda equina or incomplete lesions [1 report each]), 1 paper indicated that removal of the bullet was of benefit between T-12 and L-4 in either incomplete or complete SCI, and 5 papers indicated that there was no evidence to support the use of decompressive laminectomy.

DiscussionHistory

An early and one of the most well-known fatalities due to a PSI was that of the great British naval Vice Ad-

TABLE 1: Demographics of patients with PSIs in military conflicts*

Authors & Year Conflict No. of Patients Mean Age (yrs)

Janković et al., 1998 Croatian War 96 (86 soldiers, 10 civilians [4 F, 6 M]) 28.3 (soldiers), 38.8 (civilians)Alaca et al., 2002 terrorism in Turkey 105 25Splavski et al., 1996 Croatian War 21 (10 soldiers, 11 civilians [7 M, 4 F]) 30.7Aarabi et al., 1996 Iran-Iraq War 205 (145 w/ follow-up) NAKahraman et al., 2004 terrorism in Turkey 106 21.2Ohry & Rozin, 1984 Lebanon War 12 (7 soldiers, 5 civilians) 19.7Duz et al., 2008 terrorism in Turkey 129 20.3Rukovansjki, 1996 Croatian War 20 (16 M, 4 F) NABhatoe & Singh, 2003 India 22 30.7Hammoud et al., 1995 Lebanon War 64 25Parsons et al., 1993 Operation Just Cause

(Panama)2 (M) 23

total 782 19.7 (soldiers), 38.8 (civilians)

* NA = not available.

P. Klimo et al.


TABL

E 2:

Neu

rolo

gica

l out

com

e of P

SIs s

usta

ined

dur

ing

mili

tary

confl

ict*

No. o

f Pati

ents

(%)

Mec

hanis

mLe

vel o

f Injur

y Ne

urolo

gical

Injur

y Op

Auth

ors &

Ye

arGS

WEx

pl/Bl

ast

Cer-

vical

Tho-

racic

Lum

-ba

rSa

cral

CSCI

ISCI

Lami

nec-

tomy

Stab

ili-za

tion

Othe

r Org

an

Injur

y (%)

Suffic

ient

Data?

†Ne

urolo

gical

Resu

ltsAu

thor

s’ Op

inion

Jank

ović

et al.

, 199

849

4719

2156

NANA

276

50/9

6 (52

)no

NAde

comp

ress

ive op

is

of no

bene

fitAl

aca e

t al.,

2002

987

268

305

8817

5672

/105 (

69)

noNA

NA

Splav

ski e

t al.

, 199

612

38

82

1011

171

10/21

(48)

nono

CSC

I pt im

prov

ed; a

ll ISC

I pts

impr

oved

all pt

s w/ n

euro

logica

l de

ficit s

hould

un-

derg

o dec

ompr

es-

sive o

p imm

ediat

elyAa

rabi

et al.

, 19

9660

138

4010

263

90/14

5

(62)

55/14

5

(38)

87/14

5

(60)

49/2

05 (2

4)ye

sim

prov

ed: C

SCI+

op 24

%; C

SCI

w/o o

p 27.5

%; IS

CI+o

p 91%

, IS

CI w

/o op

100%

deco

mpre

ssive

op is

of

no be

nefit

Kahr

aman

et

al., 2

004

868

3525

4623

8365

49/10

6 (46

)ye

s36

/53 (

68%)

w/ o

p imp

rove

d; 17

/28 (

60%)

w/o

op im

prov

edde

comp

ress

ive op

is

of no

bene

fitOh

ry &

Roz

in,

1984

11

14

53

75

25/1

2 (42

)no

1 pt im

prov

ed w

/ op;

2 pts

impr

oved

w/o

opde

comp

ress

ive op

is

of no

bene

fitDu

z et a

l., 20

08

53 (3

7 high

ve

l, 16

low ve

l)

7639

3159

2410

574

2454

/129 (

41.9)

yes

56.9

% im

prov

ed w

/ op;

57.5%

im

prov

ed w

/o op

deco

mpre

ssive

op is

of

no be

nefit

Ruko

vans

jki,

1996

118

84

NANA

1213

/20 (

65)

nono

preo

p dat

a; po

stop 8

wer

e Fr

anke

l Gra

de A

or B

, 10

were

Gra

de C

or D

, 1 w

as

Grad

e E

NA

Bhato

e &

Sing

h, 20

03

4 (a

ll low

ve

l)

186

123

115

717

10/17

(59)

nono

CSC

I pt im

prov

ed; a

ll ISC

I pts

impr

oved

deco

mpre

ssive

op

is of

bene

fit in

pts

w/ in

comp

lete o

r ca

uda e

quina

injur

yHa

mmou

d et

al., 1

995

NANA

2437

347

1723

38/6

4 (59

)ye

sim

prov

ed: C

SCI+

op 0%

; CSC

I w/

o op 3

.7%; IS

CI+o

p 100

%;

ISCI

w/o

op 8

0%

deco

mpre

ssive

op is

of

no be

nefit

Pars

ons e

t al.

, 199

32

22

NAno

CSCI

pts d

id no

t impr

ove

NA

total

333

378

180

317

277

830

630

038

231

350/

775 (

45)

* CS

CI =

comp

lete S

CI; E

xpl =

explo

sion;

ISCI

= in

comp

lete S

CI; p

t = pa

tient;

vel =

veloc

ity.

† Th

e stu

dy w

as c

onsid

ered

to h

ave

suffic

ient d

ata

if th

e pa

per h

ad n

euro

logica

l outc

ome

data

for p

atien

ts wh

o un

derw

ent a

dec

ompr

essiv

e lam

inecto

my a

nd th

ose

that

were

trea

ted n

onop

era-

tively

.



5

miral Lord Horatio Nelson. A French sharpshooter felled him during the epic naval battle of Trafalgar.14 He was hit in the left shoulder, experienced immediate paraplegia, and died of his injury shortly thereafter. Other notable fatalities from spinal GSWs in history include the 20th President of the US James A. Garfield47 and the assas-sin of the 16th President of the US (Abraham Lincoln), John Wilkes Booth.39 Throughout the military conflicts of the 19th century such as the American Civil War and the Crimean, Boer, and Balkan Wars, PSIs were relatively rare, but came with a very high mortality rate, typically greater than 50%, which discouraged many from per-forming any surgical intervention.14

This reluctance to render treatment to these patients based on their grim prognosis continued into the Great War (World War I, 1914–1918). For example, during the brief but bloody American involvement, 0.4% of the in-jured had compound spinal injuries with a mortality rate of 56%.14 After the war, the British Medical Research Council, in a review of World War I spinal cord injuries, concluded that the only indication for a laminectomy was an incomplete lesion with progressive neurological loss, which admittedly was quite a rare scenario.42 At the onset of World War II (1939–1945), surgeons were faced with another onslaught of PSIs with little treatment to offer as a result of the continuation of the fatalistic attitude born through the previous conflicts. As stated by Dr. Milton Tinsley, “This was the confusion existing when we began

to care for compound spinal injuries in World War II.”42

Before becoming one of the founding fathers of pediatric neurosurgery, then Major Donald Matson28 summarized the feelings of many surgeons: “This has always been a difficult and discouraging group of cases to treat and per-haps for this reason they have been neglected.”

During the early American land campaigns of World War II such as Africa and Sicily, surgeons initially man-aged PSI using the same pessimistic philosophy of World War I. However, this was becoming increasingly unac-ceptable to surgeons. As stated by Dr. Walter Haynes,15

consultant neurosurgeon for the American First Army, “No one of us was ever satisfied with the defeatist attitude prevalent as to the prognosis of cord wounds. Yet, in light of previous experience of such men as Cushing, and the results of surgery in hardly comparable closed cord inju-ries, it seemed foolhardy to laminectomize more of those patients.”

As World War II progressed, the pendulum of opinion swung sharply in favor of aggressive surgical de bride ment, decompression of the spinal canal, and often intradural ex-ploration through a laminectomy in virtually all patients with compound spinal wounds, even those with complete neurological injuries.15,28,29,37,42 Previously unheard of results were being reported. In Pool’s series32 of 57 pa-tients treated during the years 1943–1944, 35 underwent a laminectomy and 57% showed a marked neurological improvement, compared with 4.5% spontaneous improve-

Fig. 2. This patient was shot with a 9-mm bullet and suffered an incomplete neurological injury. The CT images showed the bullet was lodged in the spinal canal at the L-3 level (A and B). The bullet was removed (C) with no change in the patient’s neu-rological examination in the immediate postoperative period.

TABLE 3: Demographics regarding PSIs sustained during civilian conflict

Authors & Year City No. of Patients & Sex Mean Age (yrs)

Cybulski et al., 1989 Chicago 83 M, 5 F 24.7Benzel et al., 1987 Shreveport 27 M, 8 F 30Kihtir et al., 1991 The Bronx 21 M 26Simpson et al., 1989 Houston 150 M, 10 F 29Waters & Adkins, 1991 Los Angeles 81 M, 9 F 29.6Heary et al., 1996 Philadelphia 222 M, 17 F 26Robertson & Simpson, 1992 Houston 30 M, 3 F 30Kupcha et al., 1990 Philadelphia 25 M, 3 F 32total 639 M, 55 F range 24.7–32

TABL

E 2:

Neu

rolo

gica

l out

com

e of P

SIs s

usta

ined

dur

ing

mili

tary

confl

ict*

No. o

f Pati

ents

(%)

Mec

hanis

mLe

vel o

f Injur

y Ne

urolo

gical

Injur

y Op

Auth

ors &

Ye

arGS

WEx

pl/Bl

ast

Cer-

vical

Tho-

racic

Lum

-ba

rSa

cral

CSCI

ISCI

Lami

nec-

tomy

Stab

ili-za

tion

Othe

r Org

an

Injur

y (%)

Suffic

ient

Data?

†Ne

urolo

gical

Resu

ltsAu

thor

s’ Op

inion

Jank

ović

et al.

, 199

849

4719

2156

NANA

276

50/9

6 (52

)no

NAde

comp

ress

ive op

is

of no

bene

fitAl

aca e

t al.,

2002

987

268

305

8817

5672

/105 (

69)

noNA

NA

Splav

ski e

t al.

, 199

612

38

82

1011

171

10/21

(48)

nono

CSC

I pt im

prov

ed; a

ll ISC

I pts

impr

oved

all pt

s w/ n

euro

logica

l de

ficit s

hould

un-

derg

o dec

ompr

es-

sive o

p imm

ediat

elyAa

rabi

et al.

, 19

9660

138

4010

263

90/14

5

(62)

55/14

5

(38)

87/14

5

(60)

49/2

05 (2

4)ye

sim

prov

ed: C

SCI+

op 24

%; C

SCI

w/o o

p 27.5

%; IS

CI+o

p 91%

, IS

CI w

/o op

100%

deco

mpre

ssive

op is

of

no be

nefit

Kahr

aman

et

al., 2

004

868

3525

4623

8365

49/10

6 (46

)ye

s36

/53 (

68%)

w/ o

p imp

rove

d; 17

/28 (

60%)

w/o

op im

prov

edde

comp

ress

ive op

is

of no

bene

fitOh

ry &

Roz

in,

1984

11

14

53

75

25/1

2 (42

)no

1 pt im

prov

ed w

/ op;

2 pts

impr

oved

w/o

opde

comp

ress

ive op

is

of no

bene

fitDu

z et a

l., 20

08

53 (3

7 high

ve

l, 16

low ve

l)

7639

3159

2410

574

2454

/129 (

41.9)

yes

56.9

% im

prov

ed w

/ op;

57.5%

im

prov

ed w

/o op

deco

mpre

ssive

op is

of

no be

nefit

Ruko

vans

jki,

1996

118

84

NANA

1213

/20 (

65)

nono

preo

p dat

a; po

stop 8

wer

e Fr

anke

l Gra

de A

or B

, 10

were

Gra

de C

or D

, 1 w

as

Grad

e E

NA

Bhato

e &

Sing

h, 20

03

4 (a

ll low

ve

l)

186

123

115

717

10/17

(59)

nono

CSC

I pt im

prov

ed; a

ll ISC

I pts

impr

oved

deco

mpre

ssive

op

is of

bene

fit in

pts

w/ in

comp

lete o

r ca

uda e

quina

injur

yHa

mmou

d et

al., 1

995

NANA

2437

347

1723

38/6

4 (59

)ye

sim

prov

ed: C

SCI+

op 0%

; CSC

I w/

o op 3

.7%; IS

CI+o

p 100

%;

ISCI

w/o

op 8

0%

deco

mpre

ssive

op is

of

no be

nefit

Pars

ons e

t al.

, 199

32

22

NAno

CSCI

pts d

id no

t impr

ove

NA

total

333

378

180

317

277

830

630

038

231

350/

775 (

45)

* CS

CI =

comp

lete S

CI; E

xpl =

explo

sion;

ISCI

= in

comp

lete S

CI; p

t = pa

tient;

vel =

veloc

ity.

† Th

e stu

dy w

as c

onsid

ered

to h

ave

suffic

ient d

ata

if th

e pa

per h

ad n

euro

logica

l outc

ome

data

for p

atien

ts wh

o un

derw

ent a

dec

ompr

essiv

e lam

inecto

my a

nd th

ose

that

were

trea

ted n

onop

era-

tively

.

P. Klimo et al.


TABL

E 4:

Neu

rolo

gica

l out

com

es af

ter P

SIs s

usta

ined

dur

ing

civili

an co

nflic

t*

No. o

f Pati

ents

(%)

Leve

l of In

jury

Neur

ologic

al Inj

ury

Op

Auth

ors &

Yea

rM

echa

nism

Cerv

i-ca

lTh

o-ra

cicLu

mbo-

sacr

alCS

CIIS

CILa

mi-

n ecto

mySt

abili-

zatio

nOt

her O

rgan

Inj

ury

Mea

n FU

Suffic

ient

Data?

Neur

ologic

al Re

sults

Auth

ors’

Opini

on

Cybu

lski e

t al.,

1989

hand

gun

00

8829

5988

NANA

no47

.5% im

prov

ed w

/ op

done

w/in

72 hr

s; 48

.1%

impr

oved

w/ o

p don

e afte

r 72

hrs

deco

mpre

ssive

op is

of

bene

fit in

caud

a equ

ina

wheth

er do

ne ea

rly or

late

Benz

el et

al.,

1987

33 ha

nd-

gun,

2 rifl

e

821

620

1513

NANA

yes

impr

oved

: CSC

I+op

100%

; CS

CI w

/o op

0%; IS

CI+o

p 10

0%, IS

CI w

/o op

75%

deco

mpre

ssive

op is

of be

n-efi

t in in

comp

lete i

njurie

s w/

evide

nce o

f com

pres

-sio

nKi

htir e

t al.,

1991

all G

SWs

07

1411

100

218

/21 (8

6)3 m

osno

no pt

sho

wed n

euro

logica

l im

prov

emen

tde

comp

ress

ive op

is of

no

bene

fitSi

mpso

n et a

l., 19

8914

2 GSW

s, 18

SW

s43

8730

9448

3110

7/160

(67)

NAye

sim

prov

ed: C

SCI+

op 13

%;

CSCI

w/o

op 15

%;

ISCI

+op 4

0%, IS

CI w

/o op

58%

deco

mpre

ssive

op is

of no

be

nefit

Wate

rs &

Adk

ins,

1991

all G

SWs

1949

2254

3632

NANA

yes

remo

val o

f bull

et im

prov

ed

motor

func

tion o

nly fo

r co

mplet

e & in

comp

lete

T12–

L4 in

juries

remo

val o

f bull

et is

bene

ficial

on

ly in

T12–

L4 re

gion

Hear

y et a

l., 19

96

219 G

SWs,

20 S

Ws

019

643

144

5244

716

9/21

9 (77

)NA

yes

impr

oved

: CSC

I+op

0%;

CSCI

w/o

op 0%

; ISCI

+op

5%, IS

CI w

/o op

21%

deco

mpre

ssive

op is

of no

be

nefit

Robe

rtson

&

Simp

son,

1992

30 G

SWs,

3 SW

s0

033

429

1821

/33 (

64)

22 w

ksye

sim

prov

ed: C

SCI+

op 10

0%;

CSCI

w/o

op 0%

; ISCI

+op

47%

, ISCI

w/o

op 71

%

deco

mpre

ssive

op is

of no

be

nefit

Kupc

ha et

al.,

1990

hand

gun

280

021

75

10/2

8 (36

)46

mos

yes

impr

oved

CSC

I+op

67%

; CS

CI w

/o op

50%

; IS

CI+o

p 50%

, ISCI

w/o

op 6

0%

deco

mpre

ssive

op is

of no

be

nefit

total

653 G

SWs,

41 S

Ws

9836

023

637

725

623

19

356/4

61 (7

7)

* FU

= fo

llow-

up; S

W =

stab

wou

nd.



7

ment in the nonoperative group. His mortality rate was 7%. Haynes reported a 39.4% neurological improvement in laminectomized patients compared with virtually zero in nonoperated patients with a mortality rate of 9.8%.15 He strongly believed that all patients with incomplete cord injuries and static or progressive neurological deficits should undergo exploration and decompression, and also that those with a complete physiological lesion should be treated if there was any suspicion that the spinal cord was intact.

This aggressive and early surgical management car-ried over into the Korean and Vietnam conflicts. Of the 300 patients with spinal injuries treated at the Tokyo Army Hospital between September 1950 and May 1952, 254 were penetrating and only 46 were closed.44 It was believed that unless other associated injuries required life-saving surgery, laminectomy was to be performed as soon as possible. Thus, 249 of the 254 open spinal injured patients underwent a laminectomy, 44 of them within 24 hours of injury, with only 3 deaths (1.2%). Neurological improvement or complete recovery was seen in 121 pa-tients (48%), although 130 (51%) did not have improve-ment. Amazingly, neurological improvement in those with complete injuries was best observed in the group with cervical cord injuries. Between 1965 and 1966 at the Neu-rosurgical Treatment Center in Saigon, Jacobs and Berg18

operated on all 32 patients with penetrating wounds, but had dismal short-term outcomes—none of the patients with complete injuries improved and only 2 patients with incomplete injuries showed any improvement prior to evacuation. In the series by Jacobson and Bors,19 all but one of their 90 patients with an open spinal injury from the Vietnam conflict had a laminectomy. However, during this time, reports from civilian trauma centers were rais-ing questions about the effectiveness of indiscriminate use of laminectomy for patients with a PSI.

Between 1966 and 1973, Stauffer et al.41 treated 185 pa-tients with GSWs of the spine from low-velocity missiles, 106 with complete lesions and 79 with incomplete lesions. None of the patients with complete lesions showed any im-provement regardless of whether they underwent a lamine-ctomy. Of the patients with incomplete lesions, 71% showed measureable neurological improvement after a laminecto-my compared with 76.5% who did not have surgery. Yashon et al.48 also found similar equivocal results between surgery

and nonoperative care and concluded the following: 1) the final neurological outcome was most closely related with the initial neurological status rather than with surgery; and 2) surgery should only be performed in grossly contami-nated wounds or in patients with progressive neurological decline. Surgery also appeared to be ineffective in the series of patients with cervical GSWs presented by Heiden et al.,17

in contrast to the Korean War experience described previ-ously. They too believed that the sole indication for surgery was progressive neurological deficit. Chronologically, this leads into our literature review.Current Literature

The purpose of this review was to evaluate the evi-dence for or against decompressive laminectomy use to treat PSIs since the Vietnam War. We started by review-ing the military medical literature and found that there were a number of issues with the quality of the data and the conclusions put forth by the authors as stated in Re-sults. Although a large number of total patients (782) have been reported from these studies, only 4 papers had a reasonable amount of operative and nonoperative data within their studies to make a legitimate statement about the efficacy of surgery. Only 2 papers asserted that sur-gery was beneficial, and neither one of these had data to support this conclusion. Despite having a bias toward surgery (17 of 21 patients had a decompressive laminec-tomy and did not report the outcomes on those who did not have surgery), Splavski et al.40 made the inappropri-ate conclusion that all patients with PSIs and a neurologi-cal deficit be treated with immediate surgery. The same flaws (bias toward surgery and lack of nonoperative data) marred the paper by Bhatoe and Singh6 in which they similarly concluded that surgery was beneficial. One paper correctly stated in their abstract the lack of ben-efit for surgery based on their observed data, but then contradictorily concluded that patients with incomplete or cauda equina injury have a better prognosis for func-tional recovery when surgery is performed.22 The highest quality papers in the military medical literature were by Aarabi et al.1 and Hammoud et al.13 In both papers, there were sufficient numbers of nonoperative and operative patients and within each, complete and incomplete neu-rological deficits, for data analysis. In both, surgery was not found to improve neurological functional recovery.

Fig. 3. This enemy combatant was injured by a large fragment from an artillery round. The fragment lodged in the spinal canal at the T11–12 level, and the patient had a complete neurological injury. The patient was treated nonoperatively. There was no neurological improvement after several months.

P. Klimo et al.


Given the aforementioned methodological deficien-cies in existing military medical literature, we performed a similar search in the civilian medical literature. Here, the quality of the literature was superior. Eight papers were identified, and of these 3 advocated a role for sur-gery. Cybulski et al.9 only evaluated patients with inju-ries of the cauda equina and concluded that surgery was of benefit whether done early (< 72 hours) or late (> 72 hours), but there were no control data (nonoperative) to support their conclusion. Benzel et al.5 concluded that surgery was indicated in those patients with incomplete injury and evidence of continued compression of neuro-logical structures within the spinal canal. In a multicenter study, Waters and Adkins45 found that bullet removal ben-efited those with complete or incomplete lesions between T-12 and L-4 (Fig. 2), but there was no effect in those between T-1 and T-11. Four papers in which there was complete preoperative, postoperative, and nonoperative data, containing patients with both complete and incom-plete neurological injury, strongly concluded that surgery was of no benefit.16,25,35,38

Our Recommendations for Deployed Military Neurosurgeons

A deployed military neurosurgeon works in an envi-ronment devoid of many administrative responsibilities,

family support responsibilities, and other issues that com-prise life. Thus, they are able to focus all of their energy on providing the best care for the casualties of war even though it may be in less than an ideal clinical setting. Repetitively facing injured soldiers and civilians with a clinical problem not often encountered in civilian prac-tice and with limited guidance is extremely unsettling. As described by World War II surgeons in the preced-ing section, the motivation to act and provide maximal intervention, regardless of whether such intervention is known to provide actual benefit, is strong. Such has been the dilemma with patients with PSI, for whom recom-mendations have not appreciably changed in more than 100 years of military conflicts.

The literature thus far for PSI has provided some an-swers to other questions.7,8,16,20,24 It is quite clear that the strongest prognostic predictor of future neurological func-tion is the initial neurological grade. There is no need to perform exploratory surgery or bullet or fragment removal as a means to reduce infection beyond local wound care unless there is gross contamination of the wound.13,43,46 A minimum of 3 days but more typically a 7–14-day course of broad-spectrum intravenous antibiotics with coverage of gram-positive, gram-negative, and anaerobic bacterial flora is effective at preventing most infections, including those in patients with transcolonic wounds.7,27,33 There is no need to operate to remove bullet fragments to prevent lead or copper toxicity as this is an extremely rare com-plication even in the new era of IEDs. There is also no role for the administration of trauma-dose Solu-Medrol in these patients.26 The only absolute indications for surgery are to repair a CSF-cutaneous/pleural fistula or if the pa-tient has progressive neurological decline correlated with compression of neural elements on imaging studies.

The question that has always been of greatest impor-tance is whether decompressive laminectomy can provide the patient a better chance at regaining neurological func-tion compared with nonoperative supportive measures. The gravity of this question is obvious when considering that the vast majority of patients who sustain PSIs in the military are young, healthy, physically active individuals, many of whom have spouses and children eagerly awaiting their return home from deployment. Does surgery work? The literature reviewed here is inconclusive, but the data reported to date suggest it does not, especially in those with complete lesions. Most of the military and civilian literature does not support surgery. Furthermore, the find-ings in the civilian literature are particularly important when one considers that the differences between civilian and military injuries make the argument for nonopera-tive treatment even stronger. Civilian injuries are almost universally caused by low-velocity projectiles that impart only a fraction of the energy to the tissue on impact in comparison with what is found in high-velocity injuries. The associated organ injuries are less severe and the wounds are less contaminated. Civilian patients can often be transported to a trauma center and can rapidly start re-ceiving advanced care. Despite significant advancement in battlefield resuscitation and transport, the process of getting a wounded warrior to a Level III Air Force The-ater Hospital, which may have neurosurgical assets, can

Fig. 4. Example of transabdominal/transspinal GSW with instability and incomplete neurological injury. This local national suffered a trans-abdominal GSW from an AK-47 that caused extensive comminution to the L-3 VB (A) as well as fractures spanning the full length of the L-4 VB (B). There was retropulsion of bone at L-3 (C). After undergoing im-mediate abdominal surgery and 1 week of intravenous antibiotics, the patient underwent an L1–S1 posterior fusion and stabilization with L-3 decompression (D).



9

be lengthy. If there is merit to the argument that early de-compression leads to better outcomes, patients extracted from a battlefield may be at a disadvantage.

However, we believe that decompressive laminectomy may be indicated for patients with penetrating SCI beyond those patients requiring repair of a CSF fistula or expe-riencing progressive neurological decline. We stress that these recommendations are the collective opinions of the authors and in no way should be interpreted as treatment standards or guidelines; each neurosurgeon or spine sur-geon must make their own clinical decision based on their opinion of the literature, their abilities, resources available at their deployment location, and each individual patient scenario:

1. Laminectomy is to be considered only if the patient is stabilized from other life-threatening injuries, most notably abdominal, thoracic, or intracranial injury.

2. Laminectomy should not be performed in patients with complete neurological injury (Fig. 3), with the possible excep-tion of patients with a cervical injury who demonstrate clear compressive pathology on imaging and arrive early after sus-taining their injury. Here, the recovery of even one spinal seg-ment is highly significant in their rehabilitive function.

3. Laminectomy should be considered in all patients with an incomplete neurological deficit (especially if the lesion is in the cauda equina) and there is evidence on imaging of signifi-cant spinal canal compromise (for example, bone or metal). Surgery should be performed as soon as possible, ideally within 24–48 hours. Segmental instrumentation and fusion should be considered at the same time if the injury is deemed unstable.

We offer these recommendations for several reasons. The available medical literature as we have detailed is far from conclusive. All the components to provide timely surgical intervention in-theater are currently in place: a well-integrated, rapid, military medical evacuation sys-tem, in-theater neurosurgeons, and medical facilities that are able to provide all aspects of perioperative care. There has been a significant change in the paradigm for delivery of neurosurgical care for the wounded military service member over the past 2 decades. Since the first Gulf War, neurosurgeons are now deployed directly in the combat theater, often quickly accessible via helicopter evacuation with times comparable to those seen at major civilian trauma centers. This previously unseen access to neuro-surgical evaluation and treatment should be considered when establishing a treatment algorithm in current and future military conflicts. Additionally, many military spinal cord and cauda equina injuries are the result of IEDs, which are low velocity shrapnel wounds similar to injuries sustained in civilian GSW injuries. Direct in-jury from a high-velocity military firearm, such as from a sniper attack, is fortunately less frequent than low-veloc-ity shrapnel wounds. Another point we believed was an important consideration was the transportation of these patients out of the operational theater to other medical facilities, typically in Europe and North America. These are long (commonly 8 or more hours) transcontinental and transoceanic flights aboard military aircraft, which may encounter significant turbulence with additional risk for further neurological injury. A similar rationale is used to support the use of decompressive craniectomy

in patients with severe head injury.4 There are several ad-ditional issues with these recommendations that require further discussion and clarification.

Perioperative ComplicationsA number of authors have cited an increased rate of

complications in patients who undergo surgery and use this finding to strengthen their argument against perform-ing surgery.1,7,16,35,38 This finding, however, has not been supported by others.12 Complications that have been re-ported include CSF leak, postoperative instability, neuro-logical decline, epidural hematoma, meningitis, and local infection. If such a difference truly exists, it would not be surprising and in fact expected, but we believe that these complications are manageable and should not dis-suade the surgeon from rendering potentially beneficial treatment.

Transgastrointestinal InjuriesProjectiles that pass through the abdomen and in

particular the colon before striking the spinal column are particularly ominous injuries. These patients typically require a life-saving laparotomy as the initial treatment. These patients are often too critically ill or have other issues such as an open abdominal wound that precludes them from being placed prone for several hours to per-form a laminectomy. Furthermore, several authors have found that the risk of developing a postoperative spinal wound infection is significantly higher in those patients with transcolonic injuries.16,33 Therefore, whether to per-form a laminectomy in patients with transgastrointestinal injuries needs a careful analysis of all issues, neurologi-cal and nonneurological. We believe that if the patient has an incomplete injury with continued canal compro-mise from bone or foreign objects, and it is thought the patient could tolerate a laminectomy, and the patient has been placed on appropriate broad-spectrum intravenous antibiotics, then a laminectomy should be performed as soon as possible. We believe that the potential of achiev-ing neurological recovery outweighs the risk of devel-oping an infection that should be readily treatable with appropriate antibiotics.

If it is thought that the patient has an unstable spine (see Instability), then the decompression and instrumenta-tion should be delayed until the patient has completed a full course of antibiotics (Fig. 4). Alternatively, the decompres-sion may be performed initially and the instability treated with segmental instrumentation in a delayed fashion or with prolonged immobility and bracing. In this circum-stance, stabilization for coalition personnel would most likely occur at a medical facility out of theater because nonnative patients would most likely have been transferred before completion of their course of antibiotics.

InstabilityAs seen in this literature review, few patients in either

the military or the civilian articles required stabilization. In general, low-velocity injuries typically seen in civil-ian casualties rarely create an unstable spine.3 However, high-velocity injuries, which are more common in mili-

P. Klimo et al.


tary patients, probably have a higher risk of instability because of the greater destructive capability of the pro-jectile. Some of the cases of instability in the literature were associated with overly aggressive laminectomy.41

The largest series of military patients with PSI requiring stabilization was recently published by Duz et al.12 Of 129 patients, 24 required stabilization, 17 of them for what the authors classified as a Type III or side-to-side injury in which the bullet passed through both facet joints and/or pedicles.

In the area of operation, spinal imaging is accom-plished with plain radiographs and CT scanning. Mag-netic resonance imaging is not available until the patient reaches medical centers in either Europe or North Amer-ica. In addition, MR imaging is often contraindicated in the wounded warrior due to retained fragments from the IEDs. Computed tomography with reconstructed images in the coronal and sagittal planes is adequate for deter-mining the integrity of the VB, spinal canal, facets, and overall alignment of the spine in the area of the injury. Severely comminuted anterior and posterior elements with evidence of segmental deformity can be indicative of instability. Furthermore, a laminectomy in the presence of an anterior or middle column injury may produce an unstable spine.

Instrumentation should be performed if deemed nec-essary as part of the decompression operation if possible. Although coalition soldiers do not typically have perma-nent orthopedic or spinal implants placed in-theater for fear of infection, the state of the major in-theater medical centers, for example the Craig Joint Theater Hospital in Bagram, Afghanistan, is such that all the intraoperative equipment and spinal instrumentation needed to perform a fusion and stabilization are available. The decision to perform an instrumented fusion must take into account the risks of a potentially increased infection rate, which can be highly variable depending on the maturity of the deployed facility versus the risks of neurological decline during a long and complicated transport in a turbulent environment. In the more than 2 years that Air Force neu-rosurgeons have been deployed to Afghanistan, a number of spinal stabilization surgeries have been performed and, to date, there have been no deep or superficial wound in-fections. However, we stress that the final determination on whether to pursue instrumentation must be made by the deployed on-site neurosurgeon or spine surgeon as he or she will have the most accurate assessment of all fac-tors that need to be taken into account when making such a decision.

ConclusionsThe treatment of patients with PSIs continues to be a

great challenge to all involved and may present considerable uncertainty for the in-theater neurosurgeon with regard to treatment. Despite the numerous conflicts of today and yes-terday, there is still ambiguity as to the role of decompres-sive laminectomy in regaining lost neurological function. It is clear that the most important factor that determines fu-ture neurological function is the initial neurological status. Surgery may or may not have a beneficial role. However, the medical literature, both civilian and military, is inad-

equate at answering this question. This underscores the great need for future studies that are currently underway. Based primarily on the lack of conclusive evidence, we be-lieve that there is a role for surgery when it is done with the hope of restoring neurological function. Despite more than 60 years of amazing advancement in medical treat-ment and technology, our recommendations are hauntingly similar to the opinions expressed by Dr. Matson28 in 1946 as a result of his experience in treating these injuries in the European Theater of Operations from 1944 to 1945:

Patients who exhibit a neurological picture consistent with an incomplete transection of the spinal cord where this picture has altered since the time of injury, especially where the neuro-logical deficit is increasing.…

Patients with a neurological picture of incomplete cord transection where x-rays reveal clear-cut encroachment on the spinal canal by a foreign body or reveal definite fracture of a lamina or pedicle with or without depressed bone fragments.…

Patients who have sizable wounds directly over or near the spinal column and are leaking spinal fluid profusely.…

Disclosure

The authors report no conflict of interest concerning the mate-rials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: P Klimo, B Ragel, M Rosner, W Gluf, RR McCafferty. Acquisition of data: P Klimo, B Ragel, M Rosner, W Gluf, RR McCafferty. Analysis and interpreta-tion of data: P Klimo, B Ragel, M Rosner, W Gluf, RR McCafferty. Drafting the article: P Klimo, B Ragel, M Rosner, W Gluf, RR McCafferty. Critically revising the article: P Klimo, B Ragel, M Rosner, W Gluf. Reviewed final version of the manuscript and approved it for submission: P Klimo, B Ragel.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Army, United States Navy, United States Air Force, or Department of Defense. The authors are employees of the United States government. This work was prepared as part of their official duties and as such, there is no copyright to be transferred.

Acknowledgment

The authors thank Shirley McCartney, Ph.D., for editorial assistance.

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Manuscript submitted January 21, 2010.Accepted February 16, 2010.Address correspondence to: Paul Klimo Jr., M.D., 88th Medical

Group, 4881 Sugar Maple Drive, Wright-Patterson Air Force Base, Ohio 45433. email: [email protected].

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